Abstract

Introduction Randomised trial data suggest that direct stenting (DS) during primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) is associated with improved markers of reperfusion, such as ST segment resolution, myocardial blush grade and TIMI flow. However, there are few data as to whether these angiographic surrogates translate into a mortality benefit.

Methods Consecutive patients attending two high-volume centres undergoing PPCI for STEMI between September 2008 and December 2010 were included in the analysis. All patients received aspirin 300 mg and clopidogrel 600 mg at point of STEMI diagnosis in the community. Use of predilatation (PD), manual thrombus aspiration (TA) and glycoprotein inhibitors (GPI) were at operator discretion. Demographic data and clinical outcomes were obtained by interrogation of local and national databases.

Results A total of 1664 patients (mean age 65.3±12.5 years, 74.7% male) underwent PPCI during the study period. We excluded 77 who were not stented from the final analysis. Overall in hospital mortality was 3.0% (47/1587), with 30-day and 1-year mortality of 4.2% (66/1587) and 7.2% (114/1587) respectively. There was a significant 1-year survival advantage in patients who underwent DS (30.2%) compared with those who were stented after PD (3.16% vs 8.63%; p<0.001). GPI use was similar in both groups (57.7% DS vs 60.7% PD; p=0.29) whereas TA was higher in those who underwent DS (73.5% DS vs 61.1% PD; p<0.0001). However, in those patients who underwent DS, there was a trend towards greater mortality with TA (3.64% TA vs 1.83% no TA; p=0.35) suggesting that it is not the reason for mortality benefit in the DS group.

Conclusion In an unselected real-world population undergoing PPCI for STEMI, DS is associated with a significant reduction in 1-year mortality. This effect appears to be independent of both GPI and TA use.

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